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Month: July 2007

POLICY: Debating SICKO’s Impact by John Irvine

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Since opening a week ago, Michael Moore’s latest documentary has focused unprecedented attention on the U.S. healthcare system. The film has brought angry protests outside movie theaters. Standing ovations from audiences. And provoked angry debate in the nation’s editorial pages. It has also done fairly well at the box office, drawing far more viewers to theaters than many experts had predicted.  According to the Hollywood Reporter, the film finished second in per-theater gross last weekend, bringing in $11.3 million at 700 screens across the country — rather a respectable showing for a movie that specializes in disturbing subjects that Americans would generally rather not talk about. So far, Sicko has generated exactly the kind of controversy that the critics predicted it would.  Moore has  already had to deny that he is planning a trip to Iran next month to view the film at an Islamic film festival. (The story turned out to be a rumor spread by conservative opponents.  The filmmaker says he received an invitation from the Iranians but declined to accept.) This week he was on CNN, lambasting the network for its healthcare coverage and getting into a near shouting match on The Larry King Show with medical correspondent Dr. Sanjay Gupta over some of the stats used in the film.

Moore went on to accuse the network of colluding with the film’s
opponents, pointing out that one of Gupta’s researchers, Paul Keckley,
the former head of Vanderbilt’s Center for Evidence Based Medicine and
a current Deloitte consultant, has done a lot of work for big health
insurers and pharma companies. (Something that could be said of a fair number of people working in the field, as THCB readers know all too well.) Could Keckley be censoring the network’s coverage?  Moore wondered out loud to himself and not-very-subtly. 

The theatrics aren’t a surprise to anyone who has followed Moore throughout his
career. Not surprisingly, the attack drew a rather hurt denial from Gupta on his
CNN blog.

Meanwhile, Moore is living up to his reputation for drawing attention to himself. Earlier this week, the filmmaker published a leaked internal memo on his web site allegedly authored by
the Blue Cross communications department.  The document reviewed the film – acknowledging that the documentary is a slickly done piece of work. [Follow the link and scroll down to read the whole thing.] The review begins as follows:

"You would have to be dead to be unaffected by Moore’s movie, he is an effective
storyteller. In Sicko Moore presents a collage of injustices by selecting
stories, no matter how exceptional to the norm, that present the health
insurance industry as a set of organizations and people dedicated to denying
claims in the name of profit. Denial for treatments that are considered
"experimental" is a common story, along with denial for previous conditions, and
denial for application errors or omissions. Individual employees from Humana and
other insurers are interviewed who claim to have actively pursued claim denial
as an institutionalized goal in the name of profit. While Humana and Kaiser
Permanente are demonized, the BlueCross and BlueShield brands appear, separately
and together, visually and verbally, with such frequency that there should be no
doubt that whatever visceral reaction his movie stirs will spill over onto the
Blues brands in every market."

Will the public hold health care providers and insurers accountable for the lapses Moore documents in his film? That remains to be seen. For many Americans who haven’t been paying attention, the documentary is undoubtedly a wake up call. There seems little doubt that people will start to ask more questions when they walk into their doctor’s office or when they sit down to pick an insurer, which is certainly enough to make some people uncomfortable. There is also little doubt that the film has added to the already fiercely burning debate between supporters of a free market based system and a government run universal healthcare system.

PODCAST REVIEW: Here’s THCB contributor Dr. Eric Novack’s take on the film from his radio show last Sunday. Two thumbs up? Er, No. Here’s Part 1 and Part 2. Eric and I will get into this a little later on, we hope!RELATED: "Sicko and Healthcare Reform", Maggie Mahar’s piece on THCB drew thousands of readers  and led to excellent discussion.

POLICY: Finally, the review– It’s A Sicko World

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I know you’ve all been dying for this. It’s my review of Sicko, up over at Spot-On.

There’s so much wrong with Michael Moore’s Sicko that it’s embarrassing, especially for a health care pundit, to reveal the emotional punch it gives you. You know that your head is being bowled over by your heart, and you also know that it’s very, very cleverly done. But that doesn’t make the message any less powerful. MORE

POLICY/POLITICS: Susan Blumenthal review of the Presidential Candidates’ health care policy

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Susan Blumenthal, M.D. has created a side-By-side Comparison of all the Presidential candidates’ health care proposals. What does it tell you? None of the Republicans have a real proposal–Rudy Guliani has made some big statements about turning the system over to consumers but no one else — including Romney — has dared say much. While Edwards has a convoluted plan (courtesy of Jonathan Gruber) and Obama has been standing far too close to David Cutler, Hillary Clinton has only announced half of hers.

Of course none of it matters too much. The journey between here and real health care reform is a long, long one. But good job by Susan and her team to put it all together.

POLICY: Carmona rips White House

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Carmon
Richard H. Carmona, Surgeon General (and new Healthline Board Member BTW) rips the Bush Administration which made him Surgeon General. He says it’s happened for a while, but apparently according to Koop, Satcher and other Surgeon Generals, it’s worse under this Administration.

"The reality is that the ‘nation’s doctor’ has been marginalized and relegated to a position with no independent budget and with supervisors who are political appointees with partisan agendas. Anything that doesn’t fit into the political appointees’ ideological, theological or political agenda is ignored, marginalized or simply buried.”

C’mon. Given this White House’s record, is anyone surprised? Should Carmona have been? And of course, when it happened, why didn’t he speak out and quit? Still, it’s good to hear about it now at least.

HOSPITALS/QUALITY: Virginia Mason–living in the future before it gets here.

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More proof that the Michael Porter-type solution is living in the future before it gets here. Another study, this one from HSC shows that Virginia Mason has improved its processes, is saving money for its customers, and is paying the financial penalty.

Michael Millenson showed the same issues were going on in Demanding Medical Excellence 10 years ago, and effectively not much has changed. Doing the right thing will send providers into bankruptcy and most intermediaries and most end customers just don’t care. Here’s the full story in Health Affairs

It’s the incentives, stupid.

UPDATE: Jamie Robinson interviews Gary Kaplan, Virginia Mason’s CEO. No video, though, Brian!

INTERNATIONAL: Ian Morrison vacationing at the taxpayer’s expense

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My old boss Ian Morrison has been in Australia studying the health care system. I’m sure this was a work visit for him with neither a bar nor a golf course in sight. He did though come back with a pretty interesting view of their changing system, called  Aussie, Aussie, Aussie which is basically a British style NHS with a robust private insurance sector layered on top of it.

The only thing I’m not so sure of is why the government—any government for that matter—would want to give people a tax break to buy private health insurance. (They do it in the UK too, BTW). Unless of course the politicians concerned planned to amakudari into private health plans later. Anyone looking at the US experience knows that exempting health insurance spending (and mortgage spending) from taxation means that we spend too much money on health care (and houses).  The only place I’ve ever seen that tax break successfully taken away was in the UK, where the tax break for mortgage payments was phased out in the late 1980s. Of course it didn’t stop house prices from going up there too, but there’s no need to encourage it.

Still in general, like the French, the Aussies have got to a mix that most Americans outside of the Cato Institute could probably live with. Pity we can’t have it here.

TECH: Granger on the UK’s NPfIT

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On his way out the door Richard Granger is interviewed in CIO Magazine about the NPfIT in the UK’s NHS. A quick summary:

1) The budget scope went up because there was no PACS in the original program. The original program budget has stayed the same and they are paying for stuff as it’s delivered—late deliveries mean no payment so they’ve spent less than 1.5Bn GBP so far

2) Much of the confusion over whether the budget is blown or not  is because (at least in everyone but Granger’s mind) there is no clear budget division between existing programs (e.g. email programs for all the NHS) and Granger’s spend. “We are not paying suppliers a penny more than we were supposed to.” And of course lots of suppliers seem to agree (Accenture has bailed, iSfot is in distress, etc). But that’s not his problem “Did it cost taxpayers money to change contractors? No. We fought hard to protect taxpayers’ interests, to stay focused on getting what we paid for and only paying for what we got. I’d love to meet other CIOs who run a commercial negotiation like that with Accenture. When the news broke, three CIOs rang me to ask how on earth we’d managed it.”

4) The rest of the confusion is because, as has been shown on THCB over the years, no localization and training costs were not built into the system. Any CIO will tell you that training and adaptation tends to cost way more than software and hardware. Granger says that’s essentially not his problem and should come from the operating budget of the NHS. “If someone went on a training course, that got added in as the cost of a system. That’s when they came up with the £12bn number. Under significant pressure, I and the DoH, decided to agree to an NAO report that said the total cost of the NHS Programme would be in the order of £12bn. Notwithstanding that, the costs of the contracts that I manage have not overrun. They are under spent, currently by the best part of a billion.”

5) And what about user needs….Granger says that the suppliers are to blame but that the NHS is going to make sure that they get it right in the end.“We get a lot of views from the end user community about what is right and what is wrong and we must have a mixture of products that hopefully makes their lives easier, although sometimes we fail to do that miserably. Sometimes we put stuff in that I’m just ashamed of. Some of the stuff that Cerner has put in recently is appalling. It really isn’t usable because they have been building a system with Fujitsu without listening to what the end users want. They have taken some account but they then had to take a lot more. Now they’re being held to account because that’s my job.”

Of course now that he’s leaving it won’t be Granger doing that feet-holding.

All in all, it’s a mixed bag on the UK’s project so far. It’s certainly had it’s “good” side—notably writing tough contracts which protected the British taxpayer from massive over-runs familiar to many public works projects. It’s also had it’s bad side—especially ignoring the GP’s current ambulatory EMR vendors and not planning on integrating the local work already done. Whether the whole thing survives Granger and Blair’s passing is an interesting question. But don’t forget that compared to the US they were starting from a point of close to full ambulatory EMR adoption!

INTERNATIONAL/QUALITY: Reggie will be having a fit

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I’ve always been amused that the most cited example of the “focused factory” that Reggie Herzlinger perceives to be the answer to  medical cost and quality problems is the Shouldice Institute in Canada. That’s right the country where it takes ten months to get a doctors appointment if you’re pregnant, and where the state controls all health care—concepts Reggie’s not so keen on.

And of course the nearest thing to focused factories in the US are the specialty hospitals which—given our incentives—make most of their money increasing the amount of care given to a set populations (probably unnecessarily) and taking the most profitable cases away from the local community hospitals and away from their mission of care, or their fat endowments (Delete half the previous phrase based on your stance on the matter).

On the other hand if focused factories were established within a cost-constrained environment, presumably we’d get a clue as to whether they are more efficient and save money over all. Well maybe we’re going to find out.

Apparently London is going to be transformed into a city of 200 large multi-specialty group practices with what sounds like specialty hospitals to handle the acute care. This is going to be very interesting.

Meanwhile, in Southern California a doctor buys hospitals, kicks out managed care, jacks up prices and makes bank. Tthat’s real value add to the system

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